Problem-based learning in physical therapy: a review of the literature and overview of the McMAster University experience.

Problem-based learning (PBL) for health care

professionals is an educational method in

which learning is focused around clinical

scenarios.[[1-3] Although the use of health care

scenarios is a common denominator of PBL in the

health science professions, those scenarios alone do not

fully characterize critical philosophical and curriculum

design features of PBL. The theoretical basis of PBL is

that learning is enhanced by the following conditions:

(1) stimulation of prior knowledge, (2) learning in

context to enhance retention, and (3) elaboration of

knowledge through discussion.[4] There are several

assumptions that underlie a problem-based approach to

learning, including:

1. Students can be responsible for the breadth and

depth of learning if given direction, resources, and

feedback.

2. Students bring with them a wide background of prior

learning and experience.

3. Learning in small groups enhances understanding,

exploration, discussion, and debate.

4. Faculty tutors facilitate learning and translate

concepts rather than "teach" or serve solely as

information-givers.

5. Information used to comprehend and deal with

real-life scenarios is integrated from a variety of traditional

disciplines.

Several critical features of PBL curricula are designed to

achieve these goalsl[1-3]:

1. Learning in small groups with a faculty member as

facilitator or tutor is pivotal.

2. The role of faculty is to serve as facilitators rather than

as teachers.

3. Traditional course content, including basic sciences,

is integrated into health care scenarios.

4. Students are responsible for their own learning,

thereby allowing integration of prior knowledge and

heightening motivation for learning and the

development of lifelong learning skills.

There has been debate as to whether the theoretical

basis of PBL is sound and whether the goals for

graduates of PBL medical programs have been met.[5-7]

Concurrently, there has been growing interest in PBL by

physical therapy educators. The purposes of this article

are to discuss the development of the PBL curriculum in

physical therapy at McMaster University (Hamilton,

Ontario, Canada) and to review the current literature on

PBL. Purported and documented outcomes of PBL and

areas requiring further investigation will be outlined,

and recommendations will be made for the

implementation of PBL in other physical therapist (PT) programs.

Historical Perspective of the McMaster University PT Program

Problem-based learning began in the McMaster 

University medical program in 1965.[3] The era that gave birth to

PBL was one in which there was an accelerated growth of

technology and information as well as changing social

attitudes. Dissatisfaction with traditional medical

education and the need to address the changing social climate

led to the development of a revolutionary new medical

school curriculum.[3] The fundamental premise of this

alternative approach was that principles of learning

could be used to educate physicians more effectively with

PBL than with traditional methods. In addition, there

was an expectation of increased retention of

information, greater ability to apply knowledge in clinical

contexts, and development of lifelong learning habits.

Although changes have occurred over the years, the 

original philosophy and most of the curriculum design

concepts remain in place. Admission criteria and

methods of student evaluation to suit the program philosophy

were also developed.[3] Numerous medical schools in the

United States and around the world have adopted

various forms of problem-based curricula, including the

medical schools of Harvard University, the University of

New Mexico, and the University of Limburg.[5]

Because interprofessional education was part of the

medical school philosophy and because there was an

identified need for education programs in physical

therapy and occupational therapy, a PT program was

launched at Mohawk Community College in Hamilton,

Ontario, Canada, in 1971. Community colleges were a

new alternative to postsecondary education in Ontario 

and had a mandate to address areas of educational need

in the local community. The decision was made to foster

the existing relationship between McMaster University

and the newly founded Mohawk College of Applied Arts

and Technology through a PT program based at the

college but with the involvement of university faculty and

facilities. The new PT program combined traditional

and PBL curriculum features. These features included

integration of clinical education through a block system,

where academic units were followed by clinical

placements in related content areas with integrated

objectives. A problem-solving approach, as described by

Elstein et al,[8] was used with small-group learning in two

courses. The goals of these courses were to foster the

development of clinical reasoning and responsibility for

learning and to create a forum for students to address

patient care issues within a psychosocial framework.

In 1974, the Canadian Physiotherapy Association passed

a resolution that required all Canadian PT graduates to

have a baccaluareate degree for membership as of 1981.

The university and college leadership agreed that the PT

and occupational therapist (OT) programs would be

redesigned as new university-based programs. Following

a transitional period in which degrees were granted

through a combined college-university degree

completion process, a new university-based program admitted

its first class in 1990. In developing this program,

physical therapy faculty at Mohawk Community College and

McMaster University were given an opportunity to

develop an innovative curriculum in the milieu of the

existing innovative medical school curriculum. The

professional climate during the development of the

program was one of evolution from the physical therapist

being perceived as primarily a technician to being

perceived as a professional making decisions regarding

diagnosis and treatment. The shift away from mandatory

physician referral in Canada and in the United States

also affected the curriculum development. Physical

therapy educators were faced with the challenge of shifting

the educational focus from teaching technical skills to

educating professionals. Clinical reasoning, decision

making, and critical review and integration of research

into clinical practice received increasing emphasis.

A task force designed to reach consensus on the general

design and philosophy of the new McMaster University

PT and OT programs determined that the programs

would be problem-based. The task force included

physical therapy and occupational therapy faculty and

clinicians, other health care professionals, and members of

the community. In the development of the PT PBL,

curriculum, planners had the advantage of an

educational environment in which PBL was the norm. There

was emerging literature on PBL, and the faculty had

years of experience working with aspects of PBL in the

Mohawk Community College program and through

observing the McMaster University medical program.

Faculty had the opportunity to critically evaluate the

philosophical basis of PBL and plan a strategy for a

completely integrated PBL curriculum suitable for

physical therapy.

The McMaster University PT program is a 24-month

second undergraduate degree program. The requisite

undergraduate degree can encompass any discipline.

The curriculum plan documents objectives for each of

six units of study (Fig. 1). Content streams, such as

research, are gradually developed throughout the

program. Basic sciences, physical therapy theory, research

topics, and clinical skills are integrated through the

study of health care scenarios.

[FIGURE 1, ILLUSTRATION OMITTED]

The major educational event is a series of small-group

tutorials in which students work through the scenarios.

The skill and process of problem solving are not

emphasized, because the teaching of problem solving as a

process to enhance clinical decision making is not

supported in the literature.[9] Instead, the goals of the

health care scenarios are to provide a context for

learning, to activate prior knowledge, to motivate

students, and to stimulate discussion. Additional scheduled

educational events include clinical skills laboratories and

inquiry seminars. The intent of inquiry seminars is the

in-depth study of special topics. The new program has

maintained a strong emphasis on a humanistic approach

to patient care and developing responsible and critical

learners. A block system of academic study units followed

by clinical placements in related content areas has been

maintained to enhance the integration of academic and

clinical learning (Fig. 1).

Curriculum Design

Overview of PBL Curricular Designs

Three types of approaches to PBL have been identified

in the literature: (1) completely integrated PBL

curricula, (2) transitional curricula, and (3) a single-course

approach.[10] An integrated PBL curriculum focuses all

learning of content, including basic science, around

health care scenarios. A transitional curriculum utilizes

more traditional approaches in the early phases of the

curriculum, and there is a gradual shift to content

integration, small-group work, and student-centered

learning as students progress through the program.

Problem-based learning has also been implemented in

one or more courses of a curriculum as a trial process or

in an attempt to gain some of the proposed benefits of

PBL.[10,11]

Several advantages and disadvantages have been

identified for each design.[10] Completely integrated programs

are associated with relatively high levels of student stress

early in the curriculum.[10] This stress is thought to be due

to the challenges imposed by the concurrent

expectations of dealing with an unfamiliar learning method,

orientation to a professional program, and the volume

of content to be learned. Transitional curricula provide

students with a more gradual orientation to the skills

required for PBL and, therefore, are reportedly less

stressful for students.[10] It has been suggested, however,

that transitional curricula may lose some of the potential

benefit of PBL because content is not integrated and

related directly to clinical scenarios early in the program,

although no direct evidence is available to support this

premise. Finally, programs that have implemented PBL

on an individual course basis may achieve some of the

benefits of making content more clinically relevant, but

certain disadvantages have been identified[10,11] (1)

confusion regarding faculty-student expectations may be

imposed by presenting students with opposing

philosophies and methods, (2) faculty and student tutorial skills

and self-directed learning strategies may not develop

sufficiently, putting learning of content at risk, and (3)

several key components of PBL are not included in this

curricular design, such as integration of curriculum,

learning in context, and provision of sufficient time to

learn within traditional course schedules.[10-11]

McMaster University PT Program Curriculum Design

The McMaster University PT program is a completely

integrated problem-based curriculum. Content is

organized by body systems (musculoskeletal,

cardiopulmonary, neurological), and all relevant content, including

basic and social sciences, theory of physical therapy

practice, and clinical skills, is learned and integrated

into each system (Fig. 1). This systems approach is

distinct from traditional division of content into

academic areas of study (eg, anatomy, psychology,

statistics).[12] This design, although not unique to PBL, appears

to be common to most PBL curricula identified in the

literature because it achieves the goal of integration of

content as it relates to patient care. Study units may be

designed around any meaningful organization of

content, such as the life-span units in the McMaster

University OT program.[13] Certain concepts and topics

(streams) that cross body systems and require

development throughout the curriculum were identified during

the curriculum design phase. Examples of these streams

include therapeutic agents, patient education, human

development, scientific inquiry, and concepts such as

wellness, health promotion, and professionalism. The

streams are integrated longitudinally throughout the

curriculum. For example, Figure 2 outlines the

development of scientific inquiry throughout the curriculum.

Within each academic unit, relevant system objectives

are developed and integrated with the streams identified

for the unit. The "courses" within each unit (ie, tutorial,

clinical skills, and inquiry seminars) each deal with a

subset of the unit objectives. It was by design that courses

are named by the educational process unique to each

event, Father than by the content covered. The

McMaster, University curriculum is detailed elsewhere.[l3] This

curricular model of integrated study blocks, or units,

crossed with longitudinal streams has been described by

Snellen-Balendong.[12]

[FIGURE 2, ILLUSTRATION OMITTED]

Study Unit Design, Tutorial Process, and Health Care Scenario Development

Study Unit Design

Units of study are typically 8 academic weeks followed by

6 clinical weeks (Fig. 3). The exception to this is unit 1.

Academic blocks are divided into three courses: tutorial,

clinical skills laboratories, and inquiry seminars.

Students have approximately 16 scheduled hours per week

(Fig. 3). Tutorials are designed for small-group learning

around health care scenarios. The clinical skills

laboratories focus on hands-on clinical skills and relevant

measurement issues. Inquiry seminars are designed for

larger groups to discuss broad health care concepts and

professional issues.

[FIGURE 3, ILLUSTRATION OMITTED]

A faculty member, designated as unit chair, is

responsible for the overall coordination of each study unit. The

responsibilities of the unit chair include coordination

and ongoing review of the following: identification and

preparation of appropriate tutors, development of unit

objectives and health care scenarios, integration of the

three courses, and student/faculty evaluation. Unit

chairs work closely together with the goal of ensuring

that the unit is appropriately integrated into the

curriculum and that longitudinal streams are developed in

each unit.

Because self-directed learning is one of the premises of

PBL, schedules are developed with the goal of providing

unstructured-time to learn. It is our experience that

students spend large amounts of time accessing

resources and reading.[10,14] The ratio of nonscheduled 

study time to scheduled study time for students in the

McMaster University PT program has been reported to

be approximately 3:1.[14] No comparable data are

available for students in traditional PT programs.

The Tutorial Process

The major educational event in each unit is the tutorial.

Students meet twice per week for 2.5 to 3 hours per

session and work through health care scenarios that are

designed to address study unit objectives. Tutorial

groups are typically composed of six to nine students

and a faculty tutor. In our view, this group size is

optimum when balancing faculty resources and the

learning environment. The basic sequence for PBL in a

tutorial setting in the McMaster University PT program is

similar to that described by Barrows and Tamblyn[15]:

1. Identification of the objectives of the session and

setting of an agenda.

2. Interaction with the health care scenario:

elaboration, discussion, and activation of prior knowledge.

3. Identification of self-study questions raised during

discussion.

4. Self-directed study between tutorials (typical break is

2-3 day).

5. Discussion of acquired information and application

to the scenario.

6. Review and synthesis of what has been learned.

7. Evaluation (self, peer, tutor) at end of each tutorial.

The success of the tutorial process depends on

self-directed, responsible, and participatory learners, a

facilitatory and knowledgeable tutor, and a carefully designed

health care scenario. The role of students, including

motivation to learn and the ability to participate in the

discussion in a meaningful manner, cannot be

underestimated in the process. The role of ongoing

self-evaluation combined with student and tutor evaluation

is designed to build the skills and attributes necessary to

maximize students' learning in the tutorial group.

Tutors may be physical therapy faculty members, faculty

of other related health science disciplines, or

community PT clinicians. The question as to tutor expertise in

the field of study has been debated.[16-19] Barrows[18] Stated

that an understanding of the PBL process and skill in

tutoring are more important than knowledge in the

field, but expertise in both is the ideal circumstance. At

the outset, a decision was made that tutors in physical

therapy at McMaster University would be expert in their

understanding of PBL and in the skill of tutoring as well

as knowledgeable (not necessarily expert) in the field of

study. Several studies of medical students in PBL

programs have examined the effect of tutor content

expertise and have confirmed that knowledge in the field is

important. Silver and Wilkerson[19] demonstrated that

tutors with more content expertise tended to dominate

the tutorial discussion, potentially jeopardizing the

development of student responsibility for learning. Davis

et al,[16] however, found an insignificant difference in

tutorial interaction when comparing expert and

nonexpert tutors but higher levels of student satisfaction and

higher examination scores for groups where tutors were

content experts. Eagle et al[17] found that medical student

tutorial groups with content experts developed

approximately twice as many learning issues, and these issues

were estimated to be three times more congruent with

the objectives of the health care scenario. In addition,

these authors found that the groups with expert tutors

spent approximately twice as much time per scenario in

overcoming learning deficiencies identified within the

groups.[17]

There is evidence that tutors who are content experts are

more directive, thus determining to a larger degree than

nonexperts what the tutorial group discusses.[19,20]

Inexperienced tutors behave differently in the role than do

experienced tutors in that they tend to be more

silent.[20,21] In our view, the ideal tutor understands that

his or her role is one of a sensitive facilitator,

encouraging students to delve into issues and concepts at their will

while balancing the constraints of objectives of the

health care scenario with available time. Based on our

experience and recent literature, the tutor who is a PBL

expert and knowledgeable in the field best fills this role.

Development of Health Care Scenarios

In each academic study unit, students typically spend

between two and four tutorials working through one

health care scenario. Health care scenarios are carefully

designed to encourage students to address the objectives

of the unit. Scenarios usually depict conditions, injuries,

or diseases that are frequently dealt With in physical

therapy practice, but they may be more prototypical,

designed primarily to illustrate a critical concept. Each

scenario is designed to meet a subset of the study unit

objectives and is accompanied by a tutors' guide, which

outlines the objectives of the study unit, potential study

resources unique to the scenario, and the suggested

number of tutorials to be spent on the scenario.

The experience of the McMaster University PT program

with respect to curriculum design and health care

scenario development indicates that health care scenarios

must be carefully designed to make it easier for students

to meet objectives and balance the activation of prior

knowledge with new learning. Scenarios may range from

simple anatomical and condition-specific scenarios to

complex multisystem health care problems that

incorporate a range of psychosocial, health care, and

professional issues. We have recognized anecdotally for many

years that subtle differences in scenarios may alter how

students discuss and develop new learning issues.

Solomon et al[20] reported that the age of the patient in a

health care scenario had a direct influence on the

discussion of developmental topics. This finding has

implications for developing health care scenarios when

an objective such as human development is to be

addressed as an important objective of the scenario. This

phenomenon has important implications when selecting

patient data such as socioeconomic status, gender, and

race for inclusion in health care scenarios. In addition,

students' backgrounds must be considered when developing

scenarios. Students whose basic science and physical

therapy backgrounds differ develop different learning

issues from the same health care scenario.[10]

Solomon and colleagues[10] suggested that the complexity

of scenarios should be adapted based on students'

backgrounds to maximize students' acquisition of new

knowledge.

Curriculum Challenges

Clinical Skills

Teaching and learning clinical skills in a problem-based

PT curriculum was uncharted territory. Traditionally,

clinical skills tend to be presented in a faculty-directed

environment, with skills identified by the faculty and

taught through a process of demonstration-question-practice.

One of the curriculum challenges faced by the

McMaster University PT program has been to shift this

paradigm to a more student-directed process, where

clinical skills are integrated with other knowledge. The

model for clinical skills is that learning is in context and

the evaluation of skill development is formative as well as

summative.

An example of one model used for clinical skills is that

skills are learned around clinical vignettes, or brief

health care scenarios, that are designed to facilitate

contextual learning. Students identify learning issues

and hypotheses when the vignette is introduced.

Between clinical skills laboratories, students

independently address learning issues and identify and practice

clinical tests that they can use to assist in differentiating

among hypotheses. At a subsequent skills laboratory,

students describe, demonstrate, and practice these skills.

Feedback is provided by faculty members at that time.

Differential diagnosis, implications of clinical findings,

and determining appropriate clinical tests are addressed

by the clinical skills vignettes. Students are expected to

learn the technical aspects of clinical skills, but they also

must address the interpretation of test results, including

an understanding of the measurement properties of

tests. Learning the concepts and implications of

measurement in the context of patient care may facilitate the

ongoing application of this knowledge to clinical

practice. In summary, clinical skills are driven by clinical

scenarios, and concepts relevant to clinical practice are

integrated. There is a strong expectation that students

be self-directed, responsible learners, even though

faculty determine the specific topics and skills to be

learned.

Longitudinal Integration

The term "longitudinal integration" was coined by

Snellen-Balendong[12] to describe a curricular model with

integrated study blocks (units) crossed with longitudinal

streams (topics). During the curriculum planning phase,

numerous topics and concepts were identified that were

not specifically related to any one system-based study

unit and that required incremental development

throughout the curriculum. These topics and concepts

can be divided into three categories: (1) health care

concepts, (2) theoretical basis of physical therapy, and

(3) professional issues. Examples of health care concepts

include wellness and disability, a holistic approach to

patient care, and patient education. Examples of the

theoretical basis of physical therapy include anatomy

and physiology, human development, therapeutic

agents, and communication skills. Examples of

professional issues include strategies for development of

self-directed learning skills, communication skills (verbal,

written), and self- and peer-evaluation skills.

The objectives to be developed for each of these streams

are identified for each study unit. The curriculum

challenge is to build on these concepts sequentially,

expecting students to build on knowledge from previous units,

with minimal repetition. The development throughout

the curriculum of a holistic approach to patient care is

exemplified by the progressively increasing complexity

of health care issues, from the simple, single-joint

musculoskeletal problem with few psychosocial issues

identified in unit 1 to the complex, multisystem problem with

many psychosocial issues identified in unit 6. This

curriculum design feature requires that all faculty engage in

detailed planning of the entire curriculum and to follow

through in their respective units. In addition, tutorial

problems become unique to the curriculum and

interdependent.

Student and Faculty Role Shifts

Self-directed learning is a process by which individuals

take the initiative to diagnose their learning needs,

formulate learning goals, identify human and material

resources, choose and implement learning strategies,

and measure learning outcomes.[22] The rationale 

originally proposed for self-directed learning was that

proactive learners learn more, that the process meets our need

to be independent as we mature, and that the skills of

inquiry necessary to keep pace with expanding

knowledge are developed. One of the primary goals of PBL is

to develop self-directed learners-for-life.[18] Students in

PBL programs are explicitly and implicitly expected to

be responsible for their learning, including accessing

appropriate resources independently and spending as

much time and effort as required to learn the content.

There is freedom to choose resources and to set learning

priorities. To assist students in developing an

understanding of when an appropriate depth of learning has

been achieved, they receive ongoing informal and

formal evaluation (self, peer, and faculty).

Physical therapist curriculum content is traditionally

faculty-centered. Problem-based learning programs shift

the emphasis from faculty-centered learning to more

student-centered learning. It is important to note that

learning may be self-directed while still faculty-centered.

An example of this is an assignment of an independent

study topic by faculty. The goal of having students

identify their own learning needs and build on previous

knowledge may not be achieved even though they are

demonstrating self-directed learning. The shift from

faculty-centered learning to student-centered learning

progresses throughout the McMaster University PT

program. Students may have difficulty identifying and

prioritizing concepts and topics that require further study

early in the program, but these skills are developed

through self-evaluation and peer and tutor feedback.

Although student-centered learning is an important

component of a PBL curriculum, there are several

caveats: (1) The shift in responsibility for learning is

developed in an incremental manner through ongoing

self, peer, and faculty evaluation, (2) all course content

is not equally suited to student-centered learning (eg,

manual clinical skills require specific guided feedback,

and the learning will be appropriately more

faculty-centered), and (3) student-centered learning must

occur within the context that there is core curriculum

content required to practice as a physical therapist and

for program accreditation.

In our experience, the transition to student-centered

learning necessitates a paradigm shift for faculty

members. Students' confusion regarding faculty expectations

may undermine the process if this paradigm shirt does

not occur. Faculty members must become facilitators of

learning, rather than givers of information. Although

content expertise and the ability to transmit information

and translate concepts in an understandable manner

remain important, other attributes and skills are

important for faculty members. These attributes and skills

include (1) strategies for fostering self-directed learning,

(2) understanding when student-centered versus

faculty-centered learning is desirable and clearly articulating

these expectations to students, (3) the ability to give,

receive, and act on feedback from students and other

faculty, and (4) commitment to the global program

curriculum in order to facilitate longitudinal

integration. It is our experience that faculty may be called on to

share expertise in their field directly with students less

frequently in a PBL program than in a more traditional

curriculum. Faculty must be prepared to work at

multiple levels of student understanding at a given time

because students develop questions at various levels and

paces. The relationship between faculty and students

tends to be one of mentor and resource rather than a

more formal teacher-student relationship.

In our view, the shift in faculty role requires considerable

preparation and support. The need for clearly defined

formal support has also been documented in the

literature.[23-25] Problem-based learning and tutorial training

workshops are critical in developing the faculty

members' role as tutor.[23-25] The McMaster University PT

program pairs inexperienced and experienced tutors for

training. Tutors also meet with unit chairs regularly to

discuss unit objectives, tutorial group progress, and

health care scenarios. Evaluation by students is also an

important source for development of tutoring skills.

Involvement in ongoing curriculum review is expected,

and many faculty members are involved in research

projects to investigate the process and outcomes of PBL.

Student Evaluation

In the original McMaster University medical school

program, the focus of student evaluation was verbal

feedback within the tutorial group, rather than formal

traditional. student evaluation. One of the challenges

faced in developing the McMaster University PT

program was to determine the appropriate combination of

student evaluation methods to meet the goals of

measuring knowledge and clinical skills as well as attributes

such as self-directed learning, ability to work with and

learn in a small-group setting, and ability to apply

knowledge in clinical settings. To accomplish this task,

traditional and nontraditional evaluation methods are

used. Ongoing formal and informal peer and faculty

feedback is given regularly in tutorial groups.

Traditional methods of student evaluation such as

multiple-choice examinations and written reports are used in

addition to more nontraditional methods such as

modified essay question examinations[26] and the objective

structured clinical examination[27] for clinical skills.

Problem-Based Learning Outcomes: Review of Literature

The following advantages of a PBL curriculum over

traditional curricula have been purported or

documented:

1. Students will have enhanced problem-solving and

clinical reasoning skills.[1,28]

2. Students will be more self-directed, enthusiastic

learners, and graduates will be responsible

learners-for-life.[1,29]

3. Student's knowledge will be better retained,

retrieved, and applied in clinical settings.[1,4,29]

4. Graduates will demonstrate a more holistic approach

to patient care.[7]

5. Problem-based learning is more enjoyable for

students and faculty.[7,29]

6. The curriculum is inherently current and

evidence-based.

The following disadvantages of a PBL curriculum have

been purported or documented:

1. Increased financial and faculty time expenditure.[6]

2. Lower levels of content-specific knowledge.[6,7]

There is an increasing amount of literature that

addresses many of the purported advantages and

disadvantages of a PBL curriculum versus a traditional

curriculum.[5-7] Each issue will be addressed individually.

Problem-Solving and Clinical Reasoning Skills in Students and Graduates of

Problem-Based Learning Curricula

One of the original goals of PBL was to provide students

with practice using a problem-solving process.[1,8,15]

Recent evidence suggests, however, that clinical

expertise is more related to knowledge than to expertise in

problem solving and that it is rare for clinical experts to

use a defined problem-solving process.[9] Norman[9]

described a more rapid process than problem solving

that involves comparison of the current situation or set

of clinical findings with previous instances in memory, or

pattern recognition. The more expert the clinician, the

more likely it is that pattern recognition will be used

except in complex situations.

Studies[5,29,30] have shown no difference in

problem-solving processes or ability between students in PBL

curricula and those in traditional curricula. The

difficulty, in measuring a cognitive process such as problem

solving or clinical reasoning has been discussed by

Berkson.[5] Experience and evidence have led many PBL

experts to rethink the goal of teaching the process of

problem solving, and it is no longer considered to be a

primary objective of PBL. The goal of tutorial health

care scenarios is to provide a clinical context for the

acquisition of knowledge, rather than to solve the

problem. There are no studies that have directly compared

the effects of varying the emphasis on the

problem-solving in PBL programs.

Self-Directed Learning Skills

Enhanced self-directed learning behaviors, as evidenced

by high levels of resource use and time spent studying,

have been reported for students in PBL curricula.[10,31]

Students in two problem-based PT programs were

reported to spend 2 to 4 hours searching for literature

and 4 to 11 hours in self-directed study per tutorial

session. The lower ranges of time spent were reported

for students with a greater background knowledge and

with less unscheduled time for study. Both PBL groups

reported using journal resources as an integral part of

their study, even in the first several weeks of the

program. These findings suggest that students in PBL

curricula are engaged in self-directed learning, are

diagnosing learning needs based on prior knowledge, and

are searching for a variety of appropriate resources.[10] No

direct comparisons of resource use and study time

between students in traditional PT programs and those

in PBL programs are available. Rankin[31] concluded that

students in PBL programs placed more emphasis on

journals and on-line searches and made greater use of

the library and self-selected references than did students

in traditional medical programs. Students in PBL

programs also feel more competent with

information-seeking skills.[31]

Vernon and Blake[7] concluded on the basis of a

meta-analysis that there is a greater degree of independent

study in PBL programs versus traditional programs.

There are several issues to consider when drawing conclusions

regarding learning processes, such as self-directed

behaviors in students. Studies often do not

include a representative traditional comparison group.

Berkson[5] suggested that even subtle differences among

curricula, such as library orientation, may account for

the differences reported in self-directed learning

behaviors. In a study comparing knowledge of medical school

graduates 5 to 10 years after graduation, the PBL group

demonstrated more up-to-date knowledge than a

traditionally educated group of graduates demonstrated.[32] It

is not clear whether this difference was related to

differences in undergraduate education, retention of

information, or self-directed learning skills, because the

graduates were not pretested at graduation. Further

work is needed to compare graduates of PBL programs

with those from traditional programs with respect to

self-directed learning habits.

Clinical Performance

One of the goals of PBL is to provide students with a

context for learning that maximizes knowledge

retention and increases the ability to apply knowledge in a

clinical setting. Two meta-analyses[6.7] showed a trend that

favors students in PBL programs with respect to clinical

performance. The analyses were restricted, however, by

small sample size and lack of valid measures of clinical

performance of health care professionals.

Content-Specific Knowledge and Knowledge Retention

Lower levels of content-specific knowledge for students

in PBL programs compared with students in traditional

programs have been documented.[6,7,33] In two

studies,[34,35] lower knowledge scores were found for students

in PBL curricula compared with students in traditional

curricula. The researchers reported that there was no

longer a difference in knowledge scores at follow-up 

testing 12 weeks[34] and 2 years later.[35] These findings

suggest that students in PBL curricula demonstrate

lower content-specific knowledge scores but that these

differences may be nullified by differences in retention

between students in PBL curricula and students in

traditional curricula. It has been postulated that a

traditional examination format does not adequately evaluate

the students in PBL programs.[29] Students in PBL

programs may be placed at a disadvantage when

performance is measured using traditional formats.[29] Further

work is needed to develop valid measures of knowledge

and clinical performance for students and graduates of

both traditional and PBL programs.

Holistic Approach to Patient Care

One of the goals of the McMaster University PT program

is to encourage students and graduate clinicians to deal

with all aspects of patients' problems, including physical

and psychosocial aspects. These aspects of patient care

are explicitly stated as objectives for the health care

scenarios. The potential differences in how students in

PBL programs versus students in traditional programs

relate to patients was explored in a meta-analysis by

Vernon and Blake.[7] There is no published evidence that

students in PBL programs are different from students in

traditional programs with respect to a holistic approach

to patient care.

Enjoyment by Students and Faculty

In several studies, there have been direct or indirect

measures of student and faculty perceptions of PBL.

Moore-West et al[36] reported less distress in medical

students in PBL programs than in their traditional

counterparts. Over the years, high levels of student stress

have been observed in the first months of the McMaster

University PT program. The following disadvantages may

contribute to the stress experienced by students in PBL

programs: uncertainty regarding appropriate depth of

study, time constraints, group conflicts, and difficulty

identifying and searching for resources.[10] Lower levels of

stress have been reported for students in a program with

a transitional versus a completely integrated PBL

curriculum, suggesting that acclimatizatioin to a new

educational methodology at the same time as embarking on

the demands of a professional program is difficult.

Feedback from peers and tutors, combined with a

familiarity with the process, may alleviate these disadvantages.

Two meta-analyses indicate that students and faculty

prefer PBL learning methods.[6,7] This finding must be

interpreted with caution due to the potential bias of

self-selection on the part of both faculty and students

into a PBL environment. Advantages of PBL cited by

students in problem-based PT programs were sharing of

knowledge, opportunities to develop group skills,

simulation of clinical process, tailoring of learning needs,

better retention of information, and more effective

learning.[10]

Maintenance of a Current, Evidence-Based Curriculum

The foundation of a PBL curriculum is the health care

scenario. Students search for new literature with each

new scenario studied, and the curriculum inherently

keeps pace with changes in physical therapy practice and

literature. Differences between PBL and traditional

curricula in this area have not been documented in the

literature.

Financial and Time Expenditures

A study of the cost of PBL versus traditional medical

school curricula suggested that for up to 100 students,

no increased costs were associated with PBL.[37] Faculty in

the traditional program spent a large part of their

educational time in preparation for student contact,

compared with more direct student contact in the PBL

program.[37] Shahabudin[31], compared the amounts of

time taken to cover the same content using a lecture

format versus a PBL format in two groups of students

using five sample health care scenarios given to

supplement a traditional curriculum. Shahabudin estimated

that students would require 22% more time to cover

content using a PBL format (120 weeks) versus a lecture

format (98 weeks). Potential errors in estimating the

time from this study include the difficulty in accounting

for curricular overlap in both methods, the effect of

prior knowledge in both student groups, and the

difficulty in generalizing results to other types of programs

with different curriculum designs and staffing patterns.

In addition, the degree to which students and tutors

were familiar with the process of PBL was not

documented. The time required for PBL, particularly when

balanced by evidence that retention of knowledge may

be better in students in PBL curricula, warrants further

study.[34,35]

Recommendations for Development of Physical Therapist Problem-based

Learning Curricula

Faculty Preparation

We believe that faculty preparation is critical to the

successful implementation of a PBL curriculum. The

need for faculty preparation is outlined in two

descriptive reports.[24,25] It is our experience that PBL is

enhanced when faculty understand and embrace the

philosophy and process of PBL. A willingness to make

the paradigm shift from information-giver to facilitator

of learning and the ability to trust students' capacity to

learn are critical in our view. In completely integrated

PBL curricula, there are additional demands on faculty

members to understand how each curricular component

is integrated with and affects the rest of the curriculum.

Workshops, independent reading, and faculty

discussions have been used to achieve this goal in the

McMaster University PT program. In our view, pairing of

inexperienced and experienced tutors is also useful in

tutor training.

Student Preparation

We believe that students must understand the

philosophy and process of PBL to successfully assume greater

responsibility for their learning and to understand the

role of faculty as facilitators. Students require

orientation to the tutorial process to maximize the learning that

takes place during tutorials. In our opinion, this

orientation must include understanding of group processes as

well as giving and receiving feedback. Students should

be provided with workshops on PBL and the tutorial

process as well as information on skills emphasized in

PBL curricula, such as information searching and critical

appraisal of the literature.

Clinical Education Planning

Clinical education is an extension of the process of

learning through clinical scenarios. Students in a PBL

curriculum are expected to continue to use the process

of PBL, albeit related to a real patient, including

integrating prior knowledge and searching for new skills and

knowledge. Responsibility for meeting learning

objectives and searching out appropriate experiences and

resources is carried into the clinical setting by students

in PBL curricula. Students may seem more demanding

of clinical educators to ensure that there are

opportunities to meet learning objectives. The primary role of the

clinical educator becomes one of facilitator, rather than

the more traditional information-giver. In our view,

appropriate orientation and training of clinical

educators is important in order to extend the PBL process into

clinical education.

Curriculum Maintenance

A fully integrated PBL curriculum requires that faculty

be aware of all aspects of the curriculum and how

changes in one study unit may affect the other study

units. For example, a change in age in one clinical

scenario from a young child to a middle-aged person

may mean that students do not address an aspect of

pediatrics intended originally. In addition, where there

is longitudinal integration of concepts, faculty must

understand the content covered in other study units.

Curriculum planners must be prepared to invest time

together on a regular basis to review and revise the

curriculum, as needed.

Summary

The McMaster University PT program is a completely

integrated PBL curriculum. There is an increasing

amount of evidence available that examines the

purported advantages and disadvantages of this educational

method. In many cases, this evidence is descriptive and

quasi-experimental due to the difficulty in obtaining

matched groups of students in traditional and PBL

health care professional programs and controlling

confounding variables. In addition, the paucity of valid

measures of clinical and professional behaviors and

performance of health care professionals limits

comparison of student outcomes.

In the area of clinical performance, two meta-analyses

demonstrated that graduates of PBL medical school

curricula were superior to graduates of traditional

medical school curricula.[6,7] Lower levels of content

knowledge have been reported for medical students in PBL

programs versus their traditional counterparts.[6,7,23,34,35]

On the other hand, improved knowledge retention was

demonstrated in two studies.[34,35] Comparison of current

knowledge of medical school graduates of PBL versus

traditional curricula between 5 and 10 years after

graduation demonstrated that the graduates of PBL curricula

had more up-to-date knowledge.[32]

The development of self-directed and responsible

learners is one of the goals of PBL. There is evidence that

medical students in PBL programs place more emphasis

on journals and literature searches than students in

traditional programs do.[31] High levels of resource use

and time spent studying have been reported for PT

students in two PBL programs.[10,14] There is evidence

that medical students require more time to cover the

same content in a PBL format than in a traditional

format.[38] Direct comparisons of learning processes,

including comparisons of self-directed learning behaviors

and time to cover content, between PT students in

PBL programs and those in traditional programs are not

available.

Some authors[6,7] have reported that students and faculty

prefer PBL learning methods. Potential bias is

introduced by self-selection of students and by faculty

self-selecting a PBL versus a traditional environment. Eagle

et Al[17] reported that the financial cost of a PBL medical

school program was no different than that of a

traditional medical school program for up to 100 students.

There is limited evidence directly comparing the time

and financial costs associated with PBL versus traditional

programs, and further work is needed in this area.

In summary, evidence comparing PBL and traditional

methods is primarily from studies of medical students

and programs. The results of studies comparing students

in PBL programs and students in traditional programs

with respect to outcomes are difficult to interpret due to

potential confounding factors and lack of valid measures

of clinical and professional performance of health care

professionals. Evidence exists that students and

graduates of PBL programs demonstrate aspects of

professional behavior, including resource use and keeping

up-to-date with the literature, that are superior when

compared with students' in traditional programs. Further

research is needed to clearly elucidate the differences in

learning processes, outcomes, and time and financial

costs between PBL and traditional PT education

methods.

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